Provider Demographics
NPI:1861915613
Name:STAAB, JONATHAN (DPT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:STAAB
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 43RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:309-743-2073
Practice Address - Street 1:850 43RD AVE STE 200-300
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-8401
Practice Address - Country:US
Practice Address - Phone:309-743-0300
Practice Address - Fax:309-743-0318
Is Sole Proprietor?:No
Enumeration Date:2017-07-24
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA089351225100000X, 225100000X
IL070-023097225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist